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Treatment of severe autoimmune diseases, particularly rheumatoid arthritis, with high-dose chemotherapy and autologous stem-cell transplantation is the subject of considerable debate (1, 2). This discussion has focused on likely outcomes, patient selection, the most appropriate regimen, and whether T-cell depletion of the stem-cell graft might decrease the risk for disease recurrence. We describe a patient with severe, treatment-resistant rheumatoid arthritis who received high-dose cyclophosphamide and antithymocyte globulin. Hemopoietic rescue was achieved with peripheral blood stem cells (PBSCs) from the patient's identical twin brother.

A 39-year-old man presented with a several-week history of nocturnal fevers, a transient erythematous rash, wrist pain and swelling, and a sore throat. The patient's erythrocyte sedimentation rate was 89 mm/h (normal range, <10 mm/h), and the ferritin level was 1240 pmol/L (normal range, 45 to 674 pmol/L). The patient was negative for rheumatoid factor. Adult-onset Still disease was diagnosed, although the subsequent course of the patient's disease was consistent with severe, seronegative rheumatoid arthritis. The patient received 30 mg of prednisolone per day, and symptoms were alleviated. However, the disease remained active for the next 7 years, despite the use of sulfasalazine, methotrexate, a combination of methotrexate and azathioprine, and gold injections. Recurrent synovitis resulted in erosive destruction of the patient's wrist, ankle, and shoulder joints, and fevers required persistent use of steroids. Total hip replacement was done because of avascular necrosis of the right hip.